NEW PATIENT CONSULTATION CLINICAL QUESTIONNAIRE
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1 NEW PATIENT CONSULTATION CLINICAL QUESTIONNAIRE 1 M a k i n g t he w o r l d s m os t b ea u t if u l c o n ne c t i o ns. Please complete this questionnaire and bring to your appointment. Feel free to retain a copy for your records. Please let us know if you have any questions or require translation assistance. Thank you! I confirm that I will read and complete this questionnaire in its entirety and will provide information truthfully and accurately to the best of my knowledge. Patient s Full Name: Patient s Signature: Date: Your Partner s Full Name: Reason for Visit: Infertility Evaluation Egg Freezing/Fertility Preservation Gynecology Evaluation Male Infertility Gender Selection Other Your Ob/Gyn s Name: Phone: ( ) Address: When was the last time you visited your Ob/Gyn? Your Primary Care Physician s Name: Phone: ( ) Address: When was the last time you visited your Primary Care Physician? Have you attended one of our Fertility Seminars? Yes No How did you first hear about CHA Fertility Center - Los Angeles? My doctor. Name and location of doctor: My family/relative. Specify relation: Friends/Colleagues/Patients. Full Name (optional): Donor/Surrogacy Agency. Specify name of agent or agency: Internet Search. Please mark all that apply: Google Healthgrades.com YouTube Yelp Vitals.com Twitter Facebook Zocdoc Other. Specify: Newspaper/Magazine. Specify name of publication / language: Television. Specify TV program name / language: Radio. Specify radio channel / language: Other. Specify: What is your ancestry / ethnic background?
2 FEMALE - GYNECOLOGIC HISTORY Are you currently trying to have a baby? Yes No How long have you been trying to have a baby? When was the first day of your last period? How old were you when you started your period? Are your periods regular or irregular? Regular Irregular How often do you get your periods? How many days of bleeding do you experience? Have there been recent changes in your menstrual patterns? Yes No Do you have pain with menstruation? Yes No Do you experience pain with sexual intercourse? Yes No Do you experience pain with ovulation? Yes No Have you experienced abnormal hair growth on your face, chin, chest or abdomen? Yes No Date of your last Pap smear? Have you ever had an abnormal Pap smear? Yes No If yes, when? Have you ever had a sexually transmitted disease? Yes No If yes, when? Have you ever had Pelvic Inflammatory Disease (PID)? Yes No If yes, when? Have you ever used an IUD? Yes No Have you ever used Oral Contraceptive Pills? Yes No What type / brand? Did you have any side effects / reactions? Yes No How many years? When did you last use the pills? Date of last Mammogram? Result: 2
3 PREVIOUS FERTILITY WORKUP AND TREATMENT Please specify if you have had any of the following tests before. Female Assessment Date Result Vaginal Ultrasound HSG Hysterosalpingogram (Dye test) Fluid Ultrasound/Sonohysterogram Day 3 FSH Anti-Mullerian Hormone Other Blood Tests Has your partner ever had a semen analysis? Yes No If yes, when? Results: Count (cell/ml) Motility (%) Morphology (% normal) Have you ever received fertility treatments before? Yes No If yes, please specify types of treatments and other information: Treatment Date # of attempts Outcome Clomid and Intercourse Clomid and IUI Gonadotropins injections and intercourse Gonadotropin Injections and IUI Other Have you had an IVF cycle in the past? Yes No If yes, please provide the following: Date of IVF Cycle # of Eggs # of Embryos Outcome Did you ever use an egg donor? Yes No Did you ever use a sperm donor? Yes No Did you ever use a gestational surrogate? Yes No 3
4 MEDICAL HISTORY Please indicate if you and/or your partner have or have had any of the following conditions: Condition Yes No Comments Anemia Bleeding disorders Blood clots in lungs or veins Thalassemia Asthma Pneumonia / Lung Disease Liver Disease / Hepatitis Acid Reflux / Heartburn Heart Disease High Blood Pressure Kidney Disease Migraines / Headaches Multiple Births Birth Defects Inherited / Genetic Disease Carrier of a Genetic Disease Fragile X Syndrome / Pre-mutation Diabetes Thyroid Disease Other Hormonal Conditions Lupus Rheumatoid Arthritis Uterine Cancer Cystic Fibrosis Tay Sachs Breast Cancer Other Cancer Fibroids Infertility Endometriosis Ovarian Cysts Familial Mediterranean Fever Other 4
5 CURRENT MEDICATIONS Please list any medications that you are currently taking. Medication Dose Frequency Are you allergic to any medications? Yes No Please list. Medication Reaction to the Medication PREVIOUS SURGERIES Procedure Date Outcome / Complications Have you ever had any complications related to anesthesia? Yes No If yes, please explain: OBSTETRICAL HISTORY Have you ever been pregnant before? Yes No Date Current/ Prior Partner Live Birth Y/N Miscarriage/ Abortion/ Ectopic Wks Fetal Heart Y/N D&C Y/N Natural or C-Section Boy or Girl Weight 5
6 FAMILY HISTORY Please state if any of your family members have any of the following conditions. Condition Yes No Comments Diabetes Heart Disease High Blood Pressure Stroke Kidney Disease Liver Disease / Hepatitis Multiple Births Birth Defects Mental Retardation Fragile X Syndrome / Premutation Autism Inherited / Genetic Diseases Thyroid Disease Lupus Bleeding disorders Blood Clots in Lungs or Legs Cystic fibrosis Tay Sachs Breast Cancer Ovarian Cancer Uterine cancer Other Cancer Infertility Recurrent Miscarriage Early Menopause Sickle Cell Disease Rheumatoid Arthritis Thalassemia Familial Mediterranean Fever Other 6
7 SOCIAL HISTORY Do you use tobacco? Yes No # of packs per day Have you ever used tobacco before? Yes No # of years Do you use alcohol? Yes No # of drinks per week Do you use recreational / street drugs? Yes No If yes, what type and how often? Do you use caffeine? Yes No What type? # drinks per day Do you exercise regularly? Yes No What type of exercise do you do? Have you gained /lost weight in the last several years? Yes No Gained lbs Lost lbs What is your occupation? On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to your job: Circle a number: Are you married? Yes No If yes, for how long? How frequently do you have intercourse? times per wk / mo Do you use lubricant? Yes No EMOTIONAL STATUS On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to infertility: Circle a number: Do you see a counselor? Yes No 7
8 MALE HISTORY Please indicate if you have had any of the following conditions or procedures in the past: Conditions / Procedure Date Outcome Orchitis / Infection of the testes Undescended testes Trauma to the groin Condition requiring Chemotherapy / Radiation Vasectomy Vasectomy reversal Hernia repair Varicocele ligation Cystic fibrosis Other Please list any medications that you are currently taking. Medication Dose Frequency Are you allergic to any medications? Yes No Please list. Medication Reaction to the Medication Do you use tobacco? Yes No # of packs per day Have you ever used tobacco before? Yes No # of years Do you use alcohol? Yes No # of drinks per week Do you use recreational / street drugs? Yes No If yes, what type and how often? What is your occupation? On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to your job: Circle a number: Do you use a hot tub? Yes No If yes, how many times per week? 8
9 Are there any other aspects of your medical, surgical, family and/or social history that you think your doctor should know? COMMENTS Thank you for taking the time to complete our questionnaire. Your doctor will review this questionnaire with you. As a part of your initial evaluation your doctor may perform a focused physical exam and a pelvic ultrasound that is directed to assess reproductive health. This exam is in no way a replacement for a comprehensive routine physical exam that you should receive annually or more frequently as indicated by your age and medical history. I authorize CHA Fertility Center to (a) share my information with the companies and associates of CHA Fertility Center and CHA Health Systems and (b) aggregate and de-identify my patient information and use and share such aggregated and de-identified information for research and marketing purposes. My information shall not be shared outside of said parties without my written consent. I confirm that I have read this questionnaire entirely and have provided the information above truthfully and accurately. Patient Signature: Date: Partner Signature: Date: I confirm that I have reviewed the information above. Physician Signature: Date: Ver
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